Most gastric cancers are often in the progressive stage when diagnosed, and surgery alone is usually not adequate for treatment. Preoperative neoadjuvant therapy + radical surgery + postoperative adjuvant therapy has become the main treatment modality for progressive resectable gastric cancer worldwide.
Postoperative adjuvant therapy includes radiotherapy, chemotherapy, radiotherapy, and targeted therapy, with a preference for D2 radical surgery (lymph node dissection to station 2) + postoperative adjuvant therapy in Asia.
Who needs postoperative adjuvant therapy?
Postoperative adjuvant therapy is recommended for the following patients with gastric cancer, as recommended by the National Comprehensive Cancer Network (NCCN) guidelines.
- Patients who have not received preoperative chemotherapy or radiotherapy and have a postoperative pathologic stage of pT3 to 4NxM0 (IIA to IIIC) after R0 resection (i.e., no tumor remains microscopically), or TXN+M0 (ⅠB~ⅢC) and pT2N0M0(ⅠB) had high risk factors;
- After R1 (clean cut to the naked eye, but tumor remains visible under the microscope) or R2 resection (tumor remains visible to the naked eye);
- Patients who have received preoperative neoadjuvant chemotherapy.
- Patients who have received preoperative neoadjuvant chemotherapy.
The Chinese Society of Clinical Oncology (CSCO) guidelines recommend that patients with the following gastric cancers receive postoperative adjuvant therapy.
- After R0 resection, those with T3-4NxM0 (IIA-IIIC) and T2N0M0 (IB) have high risk factors;
- People with T2~4NxM0 (IB~IIIC) after R1 and R2 resection.
What factors do physicians consider when developing a postoperative adjuvant treatment plan?
Physicians consider multiple factors when developing a postoperative adjuvant treatment plan.
Pathological staging of the tumor
The depth of tumor infiltration, relationship to surrounding tissues, lymph node metastasis, distant metastasis, whether it invades lymphatic vessels and blood vessels, and the number of lymph nodes picked up are determined by imaging and pathological examination.
Physical condition
For patients in good health with an ECOG physical status score of ≤2, physicians typically give systematic, intense systemic therapy, including radiation, chemotherapy, and radiotherapy, which may be a combination of two or even three drugs. For those in poor health with an ECOG physical status score ≥3, dose reduction, local therapy, and systemic best support therapy are generally considered, and chemotherapy is often given as a single oral agent.
Tumor site, growth pattern, and histologic staging
The biology and malignancy of the tumor vary, and so do the treatment options chosen by the physician.
Preoperative treatment status
Preoperative tumor staging, neoadjuvant treatment options, patient tolerance, and the degree of remission after treatment all have important implications for the development of postoperative adjuvant treatment options.
What was seen intraoperatively
Whether the tumor penetrates the outermost plasma membrane of the gastric wall, whether it invades surrounding organs, and whether the surgery can achieve R0 resection all influence the development of the adjuvant treatment plan.
Individual differences, genetic polymorphisms, and genetic mutations
In patients who are HER2-positive (ie, human epidermal growth factor receptor 2), the addition of the targeted drug trastuzumab (Trastuzumab) can be beneficial, but mutations in genes such as NRAS and BRAF may render some targeted drug therapy ineffective.
Differences in gender, age, ethnicity, and region of distribution
Younger patients have high treatment needs and are well tolerated, and physicians typically give intravenous chemotherapy and three-drug combinations; older patients are often poorly tolerated and generally receive only single-drug oral therapy. Female patients with ovarian implant metastases may also have different treatment regimens.
Other
Family financial factors and patient compliance are also factors that physicians need to consider.
In summary, whether postoperative adjuvant therapy is required for patients with gastric cancer depends on the pathologic stage of the tumor, and postoperative adjuvant therapy is usually required for those with stage IB or higher. The doctor needs to consider several factors when formulating the adjuvant treatment plan. Please listen to the professional doctor’s advice and choose the most suitable treatment plan for you. (Contributed by Xin Wang, Department of Gastrointestinal Oncology, The First Hospital of China Medical University)